PHTY206 Lecture Notes - Lecture 21: Osteoporosis, Avascular Necrosis, Image Intensifier
Fractures of the proximal femur
• Introduction
o Occur commonly in the elderly population and are usually associated with a fall
from the standing position.
• They account for 50% of hip fractures with 80% affecting women.
o These fractures can be divided into two general categories based on their location
relative to the femoral attachment of the hip joint capsule:
• Intracapsular
• Extracapsular
o In severely osteoporotic bone less force is required (e.g. catching the foot and
twisting the hip into external rotation or standing from sitting).
o In young people proximal femur fractures involve higher velocity mechanisms such
as a fall from a height or direct blow in a motor vehicle accident, and these patients
often have multiple injuries with 20% sustaining an associated fracture of the
femoral shaft.
o Predictors of returning home as opposed to placement in supported
accommodation post proximal femoral fracture include:
• Younger age (<85)
• Ability to walk and perform ADLs independently prior to admission
• Living with another person and ability to walk independently on discharge
from hospital.
• Risk factors for Falls
o Intrinsic risk factors include:
• History of falls
• Increasing age (>65 years)
• Gender – women fall more often and are more likely to sustain a fracture with
a fall
• Living alone
• Ethnicity – caucasian ethnic groups fall more frequently than other ethnic
groups
• Medications - benzodiazepine use in older people is associated with an
increase of as much as 44% in the risk of hip fracture and night falls
• Medical conditions - circulatory disease, COPD, depression and arthritis are
each associated with an increased risk of 32%
• Impaired mobility and gait
• Sedentary behaviour
• Psychological status – fear of falling
• Nutritional deficiencies
• Impaired cognition
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• Visual impairments
• Foot problems
o Extrinsic risk factors include:
• Environmental hazards – poor lighting, slippery floors, uneven surfaces, pets
• Footwear and clothing
• Inappropriate walking aids or assistive devices
o Exposure to risk
• There is a complex relationship between falls, activity and risk
• Some studies show a U-shaped association whereby the most inactive and the
most active people are at the highest risk of falls
• There is an interaction between the type and extent of environmental
challenges that an older person chooses to embrace and the persons intrinsic
risk factors
• Associated injuries
o As proximal femoral fractures commonly occur following a fall, associated injuries
are common.
o This may include a Colles fracture at the wrist, rib fractures or vertebral crush
fractures.
o Assoiated ijuries ill ipat upo phsiotherap aageet ad a patiets
ability to return to their previous level of function.
o Trochanteric and subtrochanteric bone is cancellous and very well vascularised
• This contributes to a high union rate but also large fracture haematomas
which can be concealed in the thigh region.
• Classification of fractures
o Intracapsular Fractures
• Can involve the femoral head or the femoral neck and are classified according
to the degree of displacement.
• E.g. Gardes Classifiatio Sste
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o Extracapsular Fractures
• Involve the intertrochanteric and subtrochanteric regions of the proximal
femur and are classified by region.
• Extracapsular fractures are usually classified by location:
▪ Intertrochanteric fractures
▪ Subtrochanteric fractures
• Unlike intracapsular fractures, vascularity of the femoral head is not as
important a consideration when deciding on orthopaedic management of
these patients.
• Extracapsular fractures most often require open reduction and internal
fixation (ORIF) to ensure early mobilisation and prevent complications
associated with prolonged bed rest
• Considerations of Surgical Management
o With proximal femur fractures surgical management is almost always indicated as
the prolonged bed rest required for conservative management may cause disastrous
and potentially fatal complications for the patient.
o These complications include respiratory infections, vascular complications (DVT and
PE) or pressure areas
o The general principles of management are accurate reduction and surgical fixation,
along with early exercise and mobilisation to avoid potential complications
associated with immobility and prolonged bed rest.
• Gardes Tpe I ad II fratures
o Surgical Management
• Undisplaced fractures
• As a result they are less likely to result in disruption of the blood supply to the
femoral head
• Management is almost always operative involving internal fixation using a
Dynamic Hip Screw (DHS) or cannulated screws.
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Document Summary
In severely osteoporotic bone less force is required (e. g. catching the foot and twisting the hip into external rotation or standing from sitting). Living with another person and ability to walk independently on discharge from hospital: risk factors for falls. Intrinsic risk factors include: history of falls, gender women fall more often and are more likely to sustain a fracture with. Sedentary behaviour: psychological status fear of falling, nutritional deficiencies. Foot problems: extrinsic risk factors include, environmental hazards poor lighting, slippery floors, uneven surfaces, pets. Exposure to risk: there is a complex relationship between falls, activity and risk. Trochanteric and subtrochanteric bone is cancellous and very well vascularised: this contributes to a high union rate but also large fracture haematomas which can be concealed in the thigh region, classification of fractures. Intracapsular fractures: can involve the femoral head or the femoral neck and are classified according to the degree of displacement, e. g.